Basic Information
| Provider Information | |||||||||
| NPI: | 1174985089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILES | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | LEWIS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.S., CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40480 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366400480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514343626 | ||||||||
| FaxNumber: | 2514452464 | ||||||||
| Practice Location | |||||||||
| Address1: | 5721 USA DRIVE N | ||||||||
| Address2: | HAHN1119 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366080002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514459378 | ||||||||
| FaxNumber: | 2514459377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2016 | ||||||||
| LastUpdateDate: | 09/26/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 3665 | AL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SA12185 | FL | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.